It has been five years since the Affordable Care Act (ACA) became law, and new data and numerous real-life stories are beginning to reveal how close or how far the ACA has come toward meeting its objective in Washington state.

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At its core, Obamacare has one main goal: delivering affordable health care to most Americans.

And now that the U.S. Supreme Court has ruled in favor of one of its key provisions, the health-care overhaul should continue working toward that goal — at least until the next president and Congress are sworn in.

It has been five years since the Affordable Care Act (ACA) became law, and new data and numerous real-life stories are beginning to reveal how close or how far the ACA has come toward meeting its objective in Washington state.

One challenge has been expanding the reach of insurance to more people. Today, more than 91 percent of the state’s population has coverage — the highest rate in decades, according to state officials.

But coverage alone isn’t a measure of success. Equally important is whether people can afford their insurance and medical bills and whether they can get access to care that makes them healthier. That includes freebies the ACA mandates, including annual checkups, preventive screenings and birth control.

We’ve taken a tour of the health-care landscape, talking to patients, doctors and those trying to implement the overhaul of America’s health system, with the aim of better understanding what the new rules have and have not accomplished so far.

The toe index

A digital accounting of better access to care

For Sallie Neillie, saved toes are a good indication of care in a post-ACA world.

 Obamacare’s impact in Washington state

Neillie is the executive director of Project Access Northwest, a Seattle organization that helps uninsured and Medicaid patients see medical specialists. In recent months, her staff has noticed a decline in the number of people calling with untreated diabetes so severe that their circulation-damaged toes require amputation.

Patients have more access to primary care and they’re able to manage their chronic conditions, Neillie said. “They’re not as sick when they get to us.”

The system “is working,” she said. “It’s not perfect, it’s not there yet, but we’re starting to see some improvement.”

Medicaid expansion has been the largest cause of the decline in uninsured residents in Washington. Since 2014, when the no-fee health-care program expanded its definition of who could participate, the state’s Medicaid program has grown more than 40 percent, to close to 2 million enrollees.

And for residents earning too much to join Medicaid, there is the state’s insurance exchange, Washington Healthplanfinder. An ACA creation, the exchange provides discounted monthly premiums to those with lower incomes.

This year 170,000 people bought insurance from the exchange, and an equal number purchased individual coverage outside of it.

Thanks to the exchange, as well as Washington’s decision to expand Medicaid, the ACA has “achieved its goals of providing access to health insurance,” said Richard Onizuka, chief executive of the Washington Health Benefit Exchange, which oversees Healthplanfinder.

He admits affordability is still a challenge. Polls show some 46 percent of Americans with individual plans found it difficult to pay their monthly premiums, according to a recent Kaiser Family Foundation survey.

The exchange’s subsidies “make insurance much more affordable,” Onizuka said, “but people still have to pay for it and we’re still trying to help people understand that premiums are only one piece of what you pay for health care.”

Promise of “free” perks

Free benefits have a cost and aren’t always accessible

For Fraser Ratzlaff, of Seattle, the ACA actually drove up his health-care costs. Ratzlaff, 33, works at a Christian nonprofit that provides for orphaned and destitute children abroad. He had a catastrophic insurance plan pre-ACA, expecting to use it only in the case of serious illness. It cost him $100 a month.

“I wasn’t looking forward to switching over to Obamacare,” Ratzlaff said. But his insurance company canceled his “bare-bones” plan, so last year he moved to one that included all the free services the ACA required. His premium doubled and he was paying for benefits he didn’t want.

So after a few months, Ratzlaff jumped to a cheaper plan with a Christian organization. Then in January, his employer began providing coverage so he moved to its $35-a-month plan.

Except for the dental insurance, “I still don’t use it,” Ratzlaff said of his coverage.

For other Americans, the free benefits covered by insurance companies are an essential perk, yet some people are finding it hard to access them.

NARAL Pro-Choice Washington and Northwest Health Law Advocates teamed up to make sure women were getting accurate information about free contraceptives. Using “secret shoppers,” they found that wasn’t always the case, that insurance-company representatives routinely provided misinformation on contraceptive benefits.

The groups also made an online call for stories from women who were denied free contraceptives. “We got a huge response,” said Rachel Berkson, executive director for NARAL Pro-Choice Washington.

The state Office of the Insurance Commissioner has logged numerous complaints over companies failing to deliver on this and other free benefits, including colonoscopy tests to check for colorectal cancers.

The problem is so significant that the Obama administration recently issued additional information that strengthens and helps clarify the coverage of both benefits. In Washington, the insurance companies have agreed to improve communications on birth control.

Treating the newly insured

Coverage means easing discomfort and addressing the basics

Beyond free services, the ACA has brought insurance to Americans who had gone long stretches without coverage.

A recent national survey found that nearly 60 percent of people signing up for insurance through the exchanges or Medicaid were previously uninsured, according to the Commonwealth Fund. More than half the enrollees had gone more than two years without insurance.

So what sorts of health care do people forgo when uninsured? Knee-replacement surgery, according to a study from the Society of Actuaries, followed by surgeries for lower back pain and upper endoscopy, to address intestinal troubles.

They’re problems that are unpleasant, but “not acute enough to interfere with their life,” said Rebecca Owen, a health-research actuary and co-author of the report.

The study is small and based on insurance claims from patients in Kansas, but it still provides an idea about American’s unmet needs, Owen said. “This is the way the wind might be blowing,” she said.

To Dr. Kimberly Painter, Group Health Cooperative’s assistant physician in chief for continuum of care for Seattle, the bigger picture is a little different.

“When I see patients, the vast majority of the time it isn’t those expensive specialized needs that they’re coming in for,” Painter said. “They’re coming for basic stuff that people who are insured take for granted.”

That includes managing diabetes and high blood pressure, and Pap smears and mammograms for women. “It’s sad that they haven’t been respected as people to have those basic needs met,” she said.

To fulfill the increasing demand for primary care, Group Health, for one, has changed scheduling practices, lengthening clinic hours, adding a patient to a doctor’s day, and saving appointments for physicals. They’re using alternate paths to deliver care, including walk-in clinics in some Bartell Drugs locations and providing an online tool for diagnosing and treating illnesses.

So far, access seems to be keeping pace despite the new demand. The Commonwealth Fund survey showed the majority of Americans with coverage from an exchange or Medicaid could find a new primary-care doctor and get an appointment within two weeks.

Navigating coverage

The system can shunt people among a dizzying range of options

Multiple job changes and a return to school launched Heather Fisher on a health-insurance saga worthy of Odysseus.

For five years, the 37-year-old Seattleite worked in child care at a unionized business with employer-provided health insurance.

“I enjoyed the job,” Fisher said, “but the benefits that we got were a big reason for people staying.”

Fisher didn’t want to work in child care forever, so she quit in 2012 to take prerequisites for a master’s program in marriage and family therapy at Seattle Pacific University.

She became a nanny, but the wages were low and she had to drop her insurance. That meant no treatment for her fibromyalgia, a condition that can cause widespread pain and joint stiffness. She left her naturopath and stopped her monthly medication when its cost spiked. When care was urgent, she turned to family.

“I had to borrow money from my dad, which is super awesome when you’re in your 30s,” Fisher said.

She found relief when the state introduced Healthplanfinder in fall 2013. Like three-quarters of people using the exchange, Fisher qualified for federal tax credits to help pay her premiums. She purchased a $500-a-month plan that cost her $130.

Fisher left her exchange plan in September when she quit work, started her master’s program and shifted to Medicaid. She’s taking a full course load, working an unpaid internship, and expects to graduate next June.

She’s found doctors who will accept Medicaid and is pleased with the care. She no longer feels trapped in a job because it offers benefits. Because of ACA provisions that forbid insurance companies from denying coverage for pre-existing conditions, Fisher doesn’t worry about getting insured despite her fibromyalgia. For her, at least, Obamacare works.

“I feel much more in control of my own health because I’m able to ask for appointments and make appointments and not worry what it’s going to cost me to be healthy,” Fisher said. “It’s pretty freeing.”